ADDENDUM: CMA TRAINING - LIST OF COURSE ATTENDEES - …
New Jersey Department of Health Assisted Living Program
APPLICATION FOR APPROVAL OF A CERTIFIED MEDICATION AIDE TRAINING AND COMPETENCY EVALUATION PROGRAM (MATCEP) IN ASSISTED LIVING RESIDENCES/
ASSISTED LIVING PROGRAMS/COMPREHENSIVE PERSONAL CARE HOMES
ADDENDUM: CMA TRAINING - LIST OF COURSE ATTENDEES
INSTRUCTIONS: Please PRINT legibly. This form must accompany the Application for Approval (NA-4) form. It is the School Official's responsibility to verify by checking the registry that each candidate listed below is currently certified in New Jersey using the Online Public Registry at or .
School Name
Class Start Date (mm/dd/yyyy) Name of County
Name of Certified Aide
Date Verified Certificate Type* NJ Certification Number Expiration Date
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* HHHA-Homemaker/Home Health Aide
NA-Nurse Aide
PCA-Personal Care Assistant
As the School Official, I certify that I have verified by checking the registry that each candidate listed above is currently certified in New Jersey.
Name (Print) of School Official
Contact Number
Signature of School Official
Date
NA-11 OCT 13
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